A National Study Examining Emergency Medicine Specialty Training and Quality Measures in the Emergency Department.

Abstract

The objective of this study was to measure the relationship between emergency medicine (EM) specialty training and quality measures in the emergency department (ED). Data were gathered from the 2003-2004 National Hospital Ambulatory Medical Care Survey. The outcome was proportion of patients with acute myocardial infarction (AMI), pneumonia (PNA), and long-bone fracture (LBF) who received recommended therapy. These measures were analyzed with respect to EM residency completion. Compared with EDs with more than 80% EM-trained physicians, EDs with fewer than 80% EM-trained physicians had similar rates of aspirin (43% vs 42%) and beta-blocker (26% vs 19%) use for AMI, appropriate antibiotics (78% vs 83%) and pulse oximetry (51% vs 55%) for PNA, and analgesia (85% vs 79%) for LBF. Additionally, a composite end point and an adjusted model showed no statistical difference across these measures. The proportion of residency-trained EM physicians did not affect the use of recommended treatment for AMI, PNA, and LBF.

“When patients present to the emergency department (ED) for care, they assume that they will be cared for by a physician qualified to diagnose and treat their ills. This trust is even more sacred in emergency settings because patients with emergent conditions generally do not have the opportunity to choose the location or provider who will render this care. For this reason, the American College of Emergency Physicians and the American Board of Emergency Medicine advocate specific training (ie, emergency medicine [EM] residency) for physicians who treat patients in EDs.

Yet across the United States, only 69% of physicians who work in the ED are EM residency trained or EM board certified. Fewer than 40% of EDs have a majority of physicians with EM residency training, and only 1 state (Hawaii)adequate supply of EM-board-certified emergency physicians.

Although recent EM physicians are much more likely to be EM residency trained, this deficiency has been attributedto at least 4 different causes: (1) overall shortage of EM-trained physicians; (2) because EM is a relatively young specialty, a significant proportion of the workforce is composed of so-called legacy emergency physicians (ie, those engaged in EM practice prior to the proliferation of EM specialty training programs); (3) the lower staff cost of hiring non-EM-trained physicians; and (4) the difficulty of recruiting specialty trained physicians to rural locations. This variability in training of ED physicians has elicited some controversy, but the impact of the differences in training on clinical outcomes has not been assessed. EM-trained physicians are less likely to have expensive malpractice claims against them compared with their non-EM-trained counterparts.

Whether specialty training when compared to care provided by generalists leads to improved clinical outcomes for specific conditions has been reviewed more broadly in medicine, but not in the context of EM.

Because the Institute of Medicine’s 1999 report identified shortcomings in the quality of care in the US health system, there has been renewed emphasis on emphasis on identifying measures of quality and performance.

Treatment of acute myocardial infarction (AMI), pneumonia (PNA), and long bone fractures (LBFs) has been used to evaluate quality across EDs. These characteristics have been recognized as ED quality measures to varying extents. These measures evaluate the extent to which patients receive recommended therapies.”

Commentary:

Core Measures are a set of care processes developed by The Joint Commission, the nation’s predominant standards-setting and accrediting body in health care, to improve the quality of health care by implementing a national, standardized performance measurement system. The Core Measures were derived largely from a set of quality indicators defined by the Centers for Medicare and Medicaid Services (CMS). They have been shown to reduce the risk of complications, prevent recurrences and otherwise treat the majority of patients who come to a hospital for treatment of a condition or illness. Core Measures help hospitals improve the quality of patient care by focusing on the actual results of care.

This study was a national cross-sectional study of ED visits for 2003 through 2004 using the National Hospital Ambulatory Medical Care Survey (NHAMCS). The NHAMCS is administered by the Centers for Disease Control and Prevention’s NCHS and is endorsed by the Emergency Nurses Association, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, and the American College of Osteopathic Emergency Physicians.It is a national probability sample of visits to the EDs of non-governmental general and short-stay acute care hospitals located in the 50 states and the District of Columbia.

As stated above, this study was performed using cross-sectional data culled from a national database of all 50 states, and is clearly of greater quality and inspires more confidence compared to the small studies often cited to support claims of the alleged superior skills of EM residency trained physicians over their experienced, non-EM residency trained ER colleagues ( AAEM: Board Certification, Articles on Quality of Care ). Aside from having small samples, these other studies were performed with less stringent methodologies (mostly retrospective reviews) performed in only one hospital or at most, compare one hospital with another, mostly examining the effects of the introduction of an ER residency training program, the results of which can not, by any stretch of the imagination, be extrapolated to demonstrate what the AAEM and ABEM claim, that EM residency trained physicians have significantly superior clinical outcomes compared with non-EM residency trained physicians.

This quality study shows otherwise. In the discussion, it is interesting to note that the authors are hesitant to state outright what their results show, namely that when looking at nationally defined clinical criteria, non-EM residency trained and EM residency trained physicians give the same quality care. Instead, they state that the measures they used

“may be too simple to demonstrate the value of EM physicians. Future efforts to assess the role of EM training in ED quality should focus more on measures that demonstrate the unique skills of EM-trained physicians.”

What “unique skills”? The authors themselves admit that they chose these measures based on quality studies endorsed by professional societies. What the authors may be hesitant to acknowledge due to the controversy currently raging in the EM community, is that there is no significant difference in quality between EM residency trained physicians and experienced non-EM residency trained physicians, certainly not enough to warrant paying non-EM residency trained physicians much less and removing their much needed presence in the ERs.

(I am posting this “editorial” from the Floria ACEP EM Pulse mainly because when other physicians tried to respond to this piece in writing, they were informed that their letters would not be published. Therefore, in the interest of free speech and debate, I am offering this space as a forum to discuss the issues. Note: I put the phrases I found interesting in boldface, everything else is Dr. Graber’s.)

from EMpulse September / October 2007
THE EDITOR’S EMERGENCIESLike it Or Not, The Future is Emergency Medicine Residency Training
by Mylissa Graber, MD, FACEP editor@fcep.org
VP, Florida College of Emergency Physicians

I find it so sad that there are still people that think that someone does not need to be residency trained in emergency medicine in order to begin a career in emergency medicine in today’s day and age. Not only do some physicians think that way, but they actively pursue
legislation to always keep that door open and belittle what all of us have worked so hard to develop: a quality,well-trained emergency medicine specialist, who has been rigorously drilled and tested on a specific skill set that makes them capable of working extremely effectively
in any emergency department, and ready for any emergency situation. Not only do these others continue to fight this, but they do it with half truths about what we are doing and what we are trying to accomplish.

As you all should know, this past year we submitted a bill in the state of Florida to require specialty-specific residency training in order to be recognized as Board Certified in the state of Florida on a go-forward basis,meaning that anyone who has already been recognized
as board certified would still be so, but that from this point on we will close the door to those training in other fields to pursue an emergency medicine career. ABEM closed its doors 20 years ago. ACEP closed its doors eight years ago, and still, even with that, we decided in
Florida that anyone recognized up to now, 2007 or when resubmitted next year in 2008, could still be recognized, but not past that. The bill specifically states that the Florida Board of Medicine could only recognize organizations that require emergency medicine residency training
to enter the specialty as of this year, which means that all AAPS would really have to do to be recognized and end this entire ridiculous continued struggle, would be to shut the door for new diplomats to only those who have completed an accredited emergency medicine residency
program. But instead of doing that, they choose to spend thousands and thousands of dollars to “defeat us” and to continue to push state-by-state to forever keep the door open to non-residency-trained physicians entering emergency medicine. Why?

Two sessions ago we attempted to submit this bill, and I met personally with certain key legislators who could pass the bill through, including one who had sponsored the AAPS bill that failed a few years before. Interestingly, when he heard what we were trying to do,
he agreed completely and said he would support us on this. We met with him several times after and he still gave his support. Then a lobbyist for the “other side,” who apparently had been away, and who had some sort of connection to this legislator, resurfaced and the next
thing we knew, the legislator withdrew his support and we were blocked from filing the bill. Why?
Recently I was talking to a colleague I used to work with, who unbeknownst to me is BCEM certified, not ABEM certified. I knew that he was not EM trained by his practice style, but assumed he had grandfathered in to ABEM and he had never told me otherwise until
recently. I had called him about something else and he told me how he heard about the bill I was pushing and that he had received correspondence from AAPS stating that they needed to fight this bill, because it would result in the loss of his job and the end of his career, etc. He
told me he donated several thousand dollars to help them fight this “cause.” Of course, I had a lot to say about that and was furious, especially because this was blatantly
false and I was upset that as a personal friend he never came to me to inquire about what was really going on. I explained to him that the bill we submitted was not retroactive and that anyone recognized or already practicing would be able to continue to do so, that this is only
about board certification and not employment, and that this was about the future workforce of emergency medicine, not the present, and that no one entering emergency medicine today should be residency trained in anything other than emergency medicine. His response: “Oh,
well I agree with you about that. That’s not what they said. Hmm, I will need to talk to them.” I told him he gave a huge amount of money – I wish we could foster that kind of contribution for any of our other issues -against something he didn’t even agree with, because he
was given false information. He told me he was going to follow up with them, but I haven’t heard anything since. So let’s look into this for a moment. Why would an organization rally up such support from their members based on inaccurate information? And why is it that they
require specialty specific residency training for almost every other specialty except emergency medicine? What is it that is driving them so? Well, a few years ago I visited their website and found out some interesting information.

The vast majority of the new diplomats, who sit for their boards, sit for the emergency medicine boards. It would seem that we may be their “cash cow” and we could easily surmise that if they close their doors to only EM residency-trained physicians, they may be losing significant money, so they potentially have a lot at stake financially. Sad, isn’t it, that it may not be about quality after all? Interestingly, I visited the site again, and you can no longer access this information. I guess they were afraid we might catch on. There is also another website bragging about their success at “defeating” the bill that we sponsored and announcing that they are suing the New York Board of Medicine, that thanks to that they can
continue to be recognized and it states on there that this will “open the door for non-ER trained, non-ABEM certified ER physicians to continue their careers and maintain
their livelihood.”

I still do not understand what they are talking about.The physicians who have been so vocal and intricately involved in their activism and responsible for getting the Florida Board of Medicine to recognize them are far from unemployed. In fact, some of them are leaders of the
community and even directors of the ERs, own groups, etc. One I know of who is very vocal is retired, not even practicing anymore. I’m sorry that 20 years ago they missed the deadline for sitting for the ABEM boards or chose not to because they didn’t think it would matter, but there had to be a cut-off somewhere, and the natural attrition of these physicians needs to take place. The doctor who I know is in absolutely no danger of losing his job.

There are non-EM-trained physicians all over the state that are working in emergency departments and have been for 10, 20, 30 years who have very secure jobs, but
emergency medicine has become very complex, so it is inappropriate for physicians currently training in other specialties to use these alternate routes to enter emergency
medicine and call themselves board certified emergency physicians without doing the appropriate emergency medicine training. The learn-on-the-job approach
with no formal supervision or training is not only antiquated, but in today’s day and age potentially harmful and definitely unfair to our patients.
As the non-EM-trained physicians retire, they should naturally be replaced with
residency-trained emergency physicians. The argument that we will never fill all emergency departments with EM-trained physicians is a ridiculous one. More and more programs are opening up and more and more EM trained physicians are entering the field and several that I know personally have left the academic and urban world to go to some of the underserved and less-populated areas to live and practice. Even so, if a physician who is a family practice doctor chooses to work in these areas in the ED, that is fine, but s/he is still a family practice doctor,not an emergency physician and there is no shame in that.
Just don’t misrepresent who you are.In the same way,when I do a pelvic exam, I do not tell the patient I am a gynecologist, and when I put in a chest tube, I do not say I am a cardiothoracic surgeon. I’m an emergency physician and I am proud of that. You should be proud of your specialty too.
This fight is not over and we will continue to pursue residency training in EM as the only appropriate pathway into emergency medicine today, but it is time for the emergency medicine residency-trained docs to stop sitting on the sidelines and join this fight. We need your
support too. Don’t assume we’re going to fix the problem and that we will naturally prevail. We need to make our voices heard. Contribute to FLACPAC, write articles,
come to EM Days and visit your legislators at home to push this issue. Feel free to contact me and I’ll put you on a list of people who want to help and let you know how you can get involved. We don’t expect you to give thousands of dollars, but every little bit helps. When you
send your checks to FLACPAC, write residency training on the “for” line. We need to spark the same passion for the importance of residency training in emergency medicine board certification as these other physicians have in undermining our progress. Like it or not, residency training
in emergency medicine is the future. It’s just a matter of time.